Effect of academic stress, educational environment on academic performance & quality of life of medical & dental students; gauging the understanding of health care professionals on factors affecting stress: A mixed method study

Introduction Throughout their academic careers, medical and dental students face challenges that cause varying levels of stress, affecting their academic performance and quality of life (QoL). Our study aims to ascertain the effect of academic stress and the educational environment on the QoL and academic performance of medical and dental students, encompassing the perspectives of both students and healthcare professionals. Methods A mixed-method research was conducted from February to May 2022, comprising students from a medical and dental college in Pakistan. During Phase 1, the students participated in the cross-sectional survey and completed the WHO Quality of Life Scale (WHOQOL-BREF), Academic Stress Scale, and Dundee Ready Educational Environment Measure (DREEM) Inventory questionnaires. Academic performance was evaluated through last year’s annual assessment results of the students. During Phase 2 of the study, interviews with healthcare professionals who had experience as the students’ counsellors were conducted. Results The mean age of the sample (n = 440) was 22.24 ±1.4 years. The Cronbach Alpha reliability of the DREEM inventory was 0.877, that of the Academic Stress Scale was 0.939 and the WHOQOL scale was 0.895. More than half of the students (n = 230, 52.3%) reported better QoL and the majority perceived a positive educational environment (n = 323, 73.4%) and higher academic stress (n = 225, 51.1%). Males had significantly more academic stress (p<0.05). Those who perceived a positive educational environment and better QoL had better academic performance (p<0.05). Academic performance was positively and significantly correlated with QoL and academic stress (p = 0.000). In qualitative analysis, 112 codes were generated which converged into 5 themes: challenging educational environment, psychological need and support, individual differences, relationship and family life, and adjustment issues. Conclusion Medical and dental students encounter a myriad of challenges, along with significant academic stress, which detrimentally affects their academic performance, despite perceiving a positive educational environment. Conversely, a better QoL is associated with improved academic performance.


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Introduction
Academic stress is defined as a body's response to academic-related demands that exceed the adaptive capability of students. 1According to a survey carried out by the team of 'Dictionary of Human Geography' in the U.S.A, academic stress is more often seen in medical and dental students as the total prevalence of stress in medical and dental students was reported as 63% and the prevalence of severe stress was 25% which affected their quality of life and performance directly. 2High academic stress among medical and dental students is a phenomenon that transcends socio-cultural factors, economic status and course patterns. 3The higher demands associated with academic studies may interfere with demands in other domains of life and vice versa. 4Mental health is especially affected by perceived stress among medical and dental students from aged-matched non-medical student peers.Medical and dental students experience high cynicism and high emotional exhaustion due to work overload. 5emic self-efficacy, perceived stress and preferred learning styles have been linked to academic performance and have a significant effect on medical and dental college students. 6eived academic stress affects one's quality of life.Quality of life is an overarching term for the quality of various domains in life, therefore, it is a subjective multidimensional concept that defines a standard level for emotional, physical, mental, and social well-being.It is believed that for one's proper efficiency in work and good mental and physical status, one must possess a good quality of life. 7Students who disclose utilizing a multitude of self-care practices throughout their undergraduate journey in medical and dental colleges reported a decrease in the strength of the relationship between perceived stress and quality of life. 8cal schools can produce intense psychological distress in their students.However, physical exercise, sufficient leisure time and a good lifestyle can help students to be potential leaders in the field of health. 9Quality of life is an essential component of learning and has strong links to the practice and study of medicine and dentistry.There is burgeoning research to suggest that medical students are experiencing mental and psychological troubles such as perceived academic stress and burnout. 10Acute academic stresses are positive and enable a person to perform better from the start of the career, but the chronic form is the silent killer.No one is shielded from stress, but it is more prevalent in medical and dental students.The major contributing factors are an unbalanced lifestyle and study overload. 11al and psychological QOL scores were lower among medical students than among the agematched general population.The prevalence of stress symptoms was similar regardless of race, colour, and cast.The students had to struggle hard to maintain their academic performance and had been having little physical activity and disturbed sleep patterns. 12Perception about the educational environment of the institution was more positive than negative among medical students.Better performance in examinations was associated with better academic self-perception and social self-perception in students. 13d on this evidence, the present study aims to determine the effect of academic stress, and educational environment on QOL and academic performance of medical and dental students.As every place have its challenges and circumstances, this study also planned to gauge the understanding of healthcare professionals' perspective (qualitatively) on factors relevant to the academic stress of students.

Methodology
This sequential-explanatory mixed-method study was conducted on medical and dental students of a private institution in Peshawar, Pakistan from February 2022 to May 2022.The participants were recruited in March 2022.The age range was between 19 to 25 years.All the students above the age of 18 years were included in the study while students with mental health issues and 1st-year medical students were excluded from the study.The authors had access to the demographic data of the participants and individual participants could be identified during or after data collection.
During Phase 1 (Quantitative part) structured, reliable and validated questionnaires were distributed among the medical and dental students.In phase 2 (Qualitative part) interviews were conducted with healthcare professionals to explore their perspectives on the factors they considered relevant to the student's academic stress.

PHASE 1:
A cross-sectional survey was conducted including all medical and dental students from 2 nd to final year, including the purposive sampling technique.Ethical approval was taken from the Ethical Review Committee of Prime Foundation (PRIME/ERC/2022-01), Pakistan, and permission was obtained from the concerned authorities (Vice-chancellors/Dean) of the institutions before the start of data collection.All the students who participated in the study were informed about the objectives of the study and written informed consent was obtained.Demographic data were collected on structured questionnaires before collecting the data, followed by applying the following scales.

INSTRUMENTS:
World Health Organization, Quality of Life Scale: (WHO-QOL): The World Health Organization Quality of Life (WHOQOL-BREF) was used to assess the quality of life, which is an empirical instrument to assess QOL.It comprises 26 items and measures the domains of physical health; psychological health; social relationships; and environment in addition to measuring general QOL.Responses to questions are on 5 points Likert scale where "1" represents "disagree" or "not at all" and "5" represents "completely or extremely agree".Higher scores indicate better quality of life and vice versa. 16

Academic Performances:
Academic performance is the output of one's learned particular curriculum which involves assessment through tests from a particular syllabus.Annual professional exam results were taken as a measure of academic performance.The grading scale used was 1. (10-35%), 2. (35-60%), 3.

Dundee Ready Educational Environment Measure Inventory:
The 50-item DREEM questionnaire is scored on a five-point Likert scale, ranging from 0 = strong disagreement to 4 = strong agreement.The overall total ranges from 0 to 200.Of the 50 items, 9 are negatively stated items and reverse scored items.The questionnaires have been divided into five subscales: students' perception of learning (SPL), students' perception of teachers (SPT), students' academic self-perceptions (SAP), and student's perception of the atmosphere (SPA), and students' social self-perception.For the DREEM subscales, the maximum scores are 48, 44, 32, 48 and 28, respectively, the Practical Guide described by McAleer and Roff for interpreting the overall and subscale scores. 17,18 mic Stress Scale: The 40-items academic stress scale was originally developed by Kim (1970).Five-point Likert scale ranging from "no stress" to "extreme stress".The scale was classified into five sub-areas containing 8 items each: personal inadequacy, fear of failure, interpersonal difficulties with teachers, teacher-pupil relationship/teaching methods and inadequate study facilities.The total number of items was 40.Therefore 160 (4 into 8) is the maximum possible score and the highest score for each factor would be 32. 19

PHASE 2:
This was followed by in-depth qualitative interviews with 10 healthcare professionals from different departments of medical sciences.Healthcare professionals were eligible for qualitative interviews with the age range of 30 to 65 years.Professionals were purposively selected to reflect the diversity of perspectives and educational attainment.The primary investigator interviewed the health care professionals to explore their perspective on the factors they considered relevant to the student's academic stress, lasting for 40-60 minutes, transcribed into English verbatim and independently validated for coding reliability.The interview guide was developed by following the protocol for questionnaire development and was validated by the experts.

Data Analysis (Quantitative phase)
The analysis of the data was carried out using SPSS version 25.Basic variables were analysed using descriptive statistics for finding frequencies and percentages, means, and standard deviation.The internal consistency of the scales was measured through Cronbach's Alpha reliability and a value equal to or greater than 0.70 was considered satisfactory.The Chi-square test was used to find the differences between demographic variables, academic stress, performance, QOL and educational environment.In Addition, the Pearson correlation test was used to check the relation between all four components (stress, QOL, performance and environment).The results of all the tests of significance were considered significant at p < 0.05 level.

Data Analysis (Qualitative Phase)
For the qualitative part, we used thematic analysis using Virginia Braun and Victoria Clarke six steps approach to generate themes from the qualitative data.The six steps included familiarization with the data, generating initial codes, searching for themes followed by reviewing, Understanding, naming the themes, and finally producing the results. 20To ensure the quality of qualitative data we applied triangulation and member-checking methods.

Results
A total of 500 students from the private institutes of medical and dental college were asked to participate and the response rate was 80% (440).The mean age of the population was 22.24+1.5 years with the age range from 18 to 25 years.The majority were male students (n=224, 50%), who lived in the nuclear family system (n=274, 62.3%).The Cronbach alpha reliability of the DREEM inventory was 0.877, and that of the Academic Stress Scale and WHOQOL was 0.939 and 0.895 respectively.More than half of the students (n=230, 52.3%) reported better QOL, the majority perceived a positive educational environment (n=323, 73.4%) and around half of them had academic stress (n=225, 51.1%).Considering last year's annual examinations percentages of students as a tool for measuring academic performance, more than half of the students (n=387, 88%) got 60% to 85% marks and were labelled as better performers as mentioned in Table 1.
Males had significantly more academic stress (p<0.05) as compared to females.Those students who perceived a positive educational environment and better QOL had better academic performance (p<0.05), as shown in Table 2.
The Pearson correlation showed a significant moderate but negative correlation between academic performance and academic stress and similarly showed a significant moderate but positive correlation with the quality of life.In addition, the results showed a non-significant negative correlation with the educational environment.Whereas the quality of life has a significantly moderate but negative correlation between academic stress and educational environment, but a significantly moderate and positive correlation between the educational environment and academic stress, as shown in Table 3.

Qualitative Results:
We used an inductive thematic analysis approach to code the transcripts.The transcripts were read in an iterative pattern by the researchers and manually coded.Around 112 codes emerged in the first cycle of coding which converged into 9 categories of codes.The categories with mutually exhaustive meanings were converted into 5 themes.

Theme 1: Challenging Educational Environment:
Most Healthcare professionals (n=8, 80%), reported that medical and dental students are often exposed to challenging educational environments.Medical students have to fulfil multiple tasks in a short span of time and sometimes in the emotionally stressful situations of dealing with patients in pain.Such circumstances lead to perceived academic stress and affect the academic performance of the students.
Students have to fulfil multiple tasks along with dealing with the patients in a short time period, in which they have to achieve their targets in educational settings.(G=8).
However, two interviewees were of the opinion that a challenging educational environment makes the students strong and they perform well.
Challenging Educational Environment is useful in the sense that it makes people strong.

Theme 2: Psychological needs and support
All the interviewees (n=10, 100%) thought that early psychological assessment and counselling are very important for students and should be made a core component in the early years of a student's life at college.
For every student, it's essential to have an early psychological assessment and access to a counsellor to discuss their problems and stressors and to help them cope with their problems.

(G=10)
Theme 3: Individual differences The majority of the interviewees (n=9, 90%) were of opinion that students differ from each other concerning personality traits and individual characteristics, so they should be facilitated accordingly.The role of mentorship is extremely important for the better mental health performance of the students.
Students are different from each other, in every aspect, even having different personality traits that reflect in their appearance and behaviour.They face different sorts of circumstances during their course of studies.A single factor cannot affect all students in the same manner.(G8) However, one participant was of the opinion that in this age group, almost all the students are affected similarly as their challenges are somewhat the same.
Almost all the students are of the same age and face the same challenges, which lead them to academic stress and poor academic performance.(G8)

Theme 4: Social and Family relationships
Most of the interviewees (n=8, 80%) believed that social life and relationships are very important for students.A supportive parent and sibling relationship help the students to develop a positive way of thinking leading to a balanced life, less academic stress, and better performance.

The role of social and family relationships is very important in terms of a better quality of life and academic performance. A strong supportive home environment and family can reduce academic stress. (G8)
However, two of the healthcare professionals narrated that social relationships have little importance in the life of medical students as they don't have time to maintain them.
Medical and Dental students are very busy in their everyday routines, so their social relationships affect them little.(G3) Medical and Dental students can't maintain their social life at the expense of their precious time, so social relationships don't affect them significantly.(G9)

Theme 5: Adjustment issues
Most of the interviewees (n=9, 90%) reported that newly admitted students have to face adjustment issues in medical schools and especially in the hostels because of change in the environment.
These early stressors affect the students' quality of life and ultimately their academic performance.
Students should be given some window period to adjust to a new environment and the proper guidance from seniors and teachers is very important in helping them to adjust to the new environment.
Many students face adjustment difficulties at the start of the academic period, because of homesickness, along with roommates, so it's quite difficult for them and it affects their QOL and also their performance.(G9) It should be mandatory and important to give the space, a lively and friendly environment to the students to adjust to this challenging environment.(G10) However, one of the interviewees believed students have already experienced hostel life and long study hours during their entry test preparations and intermediate levels, so the adjustment to a new environment is not a big deal.
Students have already gone through such situations before like most of them have experienced hostel life and studied for more than 15 hours a day that's why they are in medical college.

Discussion
This study is an attempt to draw attention to the effects of the educational environment, and academic stress on the academic performance and quality of life of students and also gauge the perspectives of healthcare professionals on the stress levels of students in a tough educational environment.The reliability of scales, used in this study, is internally consistent and reliable.2][23] The reliability of the DREEM inventory (0.877) in our study was slightly less than the reliability of the same tool found in other studies (0.925). 246][27][28] The results of our study regarding the high prevalence of academic stress in medical and dental students have been supported by the study conducted in the USA and at King Saud University, KSA where the prevalence of academic stress among students was 30% and 63%, respectively, affecting the academic performance of the students. 1,2In our study, males had more academic stress than females which is contrary to the results of another study, in which there was no significant gender difference. 11A systematic review identified 23 studies that evaluated the relationship between academic assessment and psychological distress among female medical students which is in line with our research findings. 292] The correlation between academic stress and quality of life has been aligned with the findings of Garg K et al, in North India. 3.10,12Academic stress was significantly correlated with the educational environment which is in line with the findings of another study. 37Similarly, a systematic review and a survey carried out at Islamia University Bahawalpur, reported a negative association between academic stress and QOL among university students, which is in accordance with our research findings. 38,39ur study, students of pre-clinical and clinical years have perceived an equal amount of academic stress which is in contrast to the findings of another study, which found a high prevalence of stress in students of pre-clinical years. 11Similarly, the findings of a study conducted in Ghana confirmed that the students in senior high schools with a pleasant physical environment perform better which is contrary to our research findings. 40association between academic stress and QOL with academic performance in our study has been supported by other studies. 10,14Whereas, the correlation between academic performance and educational environment in our study is contradictory to the findings of another study conducted in Pakistan, in which a better perceived educational environment leads to better academic performance. 13ur study, the majority of the students (74%) perceived the educational environment better and had better QOL (62%) which is contrary to many other studies across the globe in which medical and dental students report average quality of life and perceive the educational environment as negative. 2,3,7,14]10 Extensive courses and training in medical and dental studies lead towards a change of psychological and physical QOL, which has been supported by a few studies. 8,12 tudies showed no significant effect of family structure on students' academic performance which is aligned with the Azumah FD study's results and contradicts Hanul P's study, which shows a significant effect of family structure. 41,42 amily support and good relationships are very important for better academic performance as per our qualitative result which is similar to a study carried out in Bangladesh. 43udy conducted in nursing college reported that work overload and academic stress lead to a challenging educational environment leading to burnout of students' psychological and mental health, supporting our qualitative theme of a challenging educational environment in the medical career leading to psychological distress. 15

Conclusion
The study concluded that most of the students are under high academic stress, because of the challenging educational environment, lack of time, and imbalance between social and personal life.Academic stress leads to poor academic performance and affects the QOL of the students, however, the educational environment has a non-significant relationship with academic performance.The role of parents, family and mentorship is very important for better mental health and academic performance.Early psychological assessment, support and Counseling should be made a part of the routine activities of students at college.

Limitations
The main limitation of our study is that we have taken two institutes only because of the time limit and feasibility of the research.Apart from that our sample size is a bit small, so in the future will focus on the longitudinal type of research with a large sample size.
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